ESPEN guidelines: Nutritional interventions in advanced cancer care. -An overview and pending research questions

Transcription

1 1 ESPEN guidelines: Nutritional interventions in advanced cancer care -An overview and pending research questions Tora Skeidsvoll Solheim, MD, PhD Oslo, October 2017

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3 3 Definition of cachexia Cancer cachexia is a multidimensional syndrome with on-going muscle loss (and often fat loss) It cannot be cured by conventional nutrition alone Leads to progressive functional impairment Fearon K, et al. Definition and classification of cancer cachexia: An international consensus. Lancet Oncology 2011

4 4 Why focus on weight loss? Progressive weight loss interferes with cancer therapy Responsible for a poor quality of life and decreased function Patients with weight loss live shorter irrespective of tumour mass or the presence of metastasis Will often cause significant psychological distress, affecting also patients next of kin In prep: ESMO guidelines for treatment of cancer cachexia

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8 8 Section C6: Patients with advanced cancer receiving no anticancer treatment

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11 11 What does this mean? Nutrition is important also in patients with advanced cancer If you do not screen you will not find patients that have reversible causes of weight loss and you will not treat

12 12 Level of evidence - Low Screening alone will not help evidence for its effect can be challenging to establish

13 13 Level of evidence - Low Screening will help acknowledging the problem Patients/family are concerned about weight loss healthcare personnel not addressing it will not reduce this anxiety Ref: Reid et al (2010) An exploration of the experiences of cachexia

14 14 Questions for research Frequency of screeing? When to stop? Difficult to answer without having effective treatment

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16 16 Level of evidence - Low Observational data from cachexia clinics show some benefit in programs treating symptoms impeding food intake, recommending exercise and give nutritional advice Ref: Del Fabbro et al (2011). Clinical outcomes and contributors to weight loss in a cancer cachexia clinic. Parmar et al. (2013). Weight changes correlate with alterations in subjective physical function in advanced cancer patients referred to a specialized nutrition and rehabilitation team. Feasibility study (premenac) shows that complex intervention is feasible and that patients are willing to participate Solheim, Laird et al. (2017) A randomized phase II feasibility trial of a multimodal intervention for the management of cachexia in lung and pancreatic cancer

17 17 Questions for research Will multimodal treatment improve outcomes? What outcomes? QoL? Survival? Physical performance? Chemotherapy deliverance?

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20 20 What does this mean? Expected benefit of nutritional intervention -Quality of life? -Survival? Burden of nutritional intervention -Biological -Psychosocial Nutritional status Expected survival Wishes of the patient and close relatives Tumor burden and available treatments

21 21 Level of evidence - Low A systematical literature review evaluating the effect of dietary counseling in patients with advanced cancer with different stages of cachexia Could not find enough proof of effect on weight and nutritional intake But it is not possible to increase or stabilise weight if nutritional needs are not met ref. Balstad et al (2014) Dietary treatment of weight loss in patients with advanced cancer and cachexia: a systematic literature review

22 22 Oral nutritional interventions Meta analysis (13 studies, 1414 patients): Nutritional intervention associated with Increased energy intake (430Kcal/d) Some weight gain (1.86 kg) Exploratory data suggesting effects on overall quality of life No effect on mortality Ref: Baldwin C, 2012

23 23 Medical nutrition Unconditional artificial nutrition during chemotherapy is associated with more harm than benefit Ref: PN in patients undergoing chemotherapy,a metaanalysis, Nutrition 1990 Only one RCT presenting effect on survival Ref: Lundholm 2004 No RCTs investigating effect of parenteral nutrition alone in patients with advanced cancer

24 24 Medical nutrition Some observational studies Ref Cotogni et al 2017

25 25 Questions for research Dosing and content of nutritional intervention? Witch patients benefit from intravenous nutrition/enteral nutrition? Witch patients have no benefit from intravenous nutrition/enteral nutrition? What are the expected benefits of nutritional interventions?

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27 27 What does this mean? Food or nutrient restrictions are avoided Psycho-social support around meals and food intake for both the patient and relatives is prioritized Monitoring of the nutritional status, e.g. recording weight changes, should be avoided to not add more stress during the final phase of life Ref: Cederholm et al ESPEN guidelines on definitions and terminology of clinical nutrition 2017

28 28 What does this mean? Artificial hydration should not be used for thirst palliation or mouth dryness Oral care measures are effective to comfort these patients

29 29 Questions for research Which patients with acute confusional states will benefit from hydration? When is the point when artificial nutrition should be avoided/stopped if previously introduced?

30 30 Thank you for the attention Trondheim University Hospital